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Beckman S, Lu H, Alsharif P, Qiu L, Ali M, Adrian RJ, Alerhand S. Echocardiographic diagnosis and clinical implications of wide-open tricuspid regurgitation for evaluating right ventricular dysfunction in the emergency department. Am J Emerg Med 2024; 80:227.e7-227.e11. [PMID: 38702221 DOI: 10.1016/j.ajem.2024.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 04/19/2024] [Indexed: 05/06/2024] Open
Abstract
The tricuspid regurgitation pressure gradient (TRPG) reflects the difference in pressure between the right ventricle and right atrium (ΔPRV-RA). Its estimation by echocardiography correlates well with that obtained using right-heart catheterization. An elevated TRPG is an important marker for identifying right ventricular dysfunction in both the acute and chronic settings. However, in the "wide-open" variant of TR, the TRPG counterintuitively falls. Failure to recognize this potential pitfall and underlying pathophysiology can cause underestimation of the severity of right ventricular dysfunction. This could lead to erroneous fluid tolerance assessments, and potentially harmful resuscitative and airway management strategies. In this manuscript, we illustrate the pathophysiology and potential pitfall of wide-open TR through a series of cases in which emergency physicians made the diagnosis using cardiac point-of-care ultrasound. To our knowledge, this clinical series is the first to demonstrate recognition of the paradoxically-low TRPG of wide-open TR, which guided appropriate management of critically ill patients in the emergency department.
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Affiliation(s)
- Sean Beckman
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Helen Lu
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Peter Alsharif
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Linda Qiu
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Marwa Ali
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Robert James Adrian
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA.
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Alerhand S, Adrian RJ. What echocardiographic findings differentiate acute pulmonary embolism and chronic pulmonary hypertension? Am J Emerg Med 2023; 72:72-84. [PMID: 37499553 DOI: 10.1016/j.ajem.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Pulmonary embolism (PE) and pulmonary hypertension (PH) are potentially fatal disease states. Early diagnosis and goal-directed management improve outcomes and survival. Both conditions share several echocardiographic findings of right ventricular dysfunction. This can inadvertently lead to incorrect diagnosis, inappropriate and potentially harmful management, and delay in time-sensitive therapies. Fortunately, bedside echocardiography imparts a few critical distinctions. OBJECTIVE This narrative review describes eight physiologically interdependent echocardiographic parameters that help distinguish acute PE and chronic PH. The manuscript details each finding along with associated pathophysiology and summarization of the literature evaluating diagnostic utility. This guide then provides pearls and pitfalls with high-quality media for the bedside evaluation. DISCUSSION The echocardiographic parameters suggesting acute or chronic right ventricular dysfunction (best used in combination) are: 1. Right heart thrombus (acute PE) 2. Right ventricular free wall thickness (acute ≤ 5 mm, chronic > 5 mm) 3. Tricuspid regurgitation pressure gradient (acute ≤ 46 mmHg, chronic > 46 mmHg, corresponding to tricuspid regurgitation maximal velocity ≤ 3.4 m/sec and > 3.4 m/sec, respectively) 4. Pulmonary artery acceleration time (acute ≤ 60-80 msec, chronic < 105 msec) 5. 60/60 sign (acute) 6. Pulmonary artery early-systolic notching (proximally-located, higher-risk PE) 7. McConnell's sign (acute) 8. Right atrial enlargement (equal to left atrial size suggests acute, greater than left atrial size suggests chronic). CONCLUSIONS Emergency physicians must appreciate the echocardiographic findings and associated pathophysiology that help distinguish acute and chronic right ventricular dysfunction. In the proper clinical context, these findings can point towards PE or PH, thereby leading to earlier goal-directed management.
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Affiliation(s)
- Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, 150 Bergen Street, Newark, NJ 07103, USA.
| | - Robert James Adrian
- Department of Emergency Medicine, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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Vignon P. Assessment of Pulmonary Arterial Pressure Using Critical Care Echocardiography: Dealing With the Yin and the Yang? Crit Care Med 2019; 47:126-128. [PMID: 30557244 DOI: 10.1097/ccm.0000000000003491] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Philippe Vignon
- Medical-Surgical Intensive Care Unit, and Inserm CIC 1435, Dupuytren Teaching Hospital; and University of Limoges, Limoges, France
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Lee JH, Lee JE, Shin J, Song IK, Kim HS, Kim CS, Kim WH, Kim JT. Clinical implications of hypothermic ventricular fibrillation versus beating-heart technique during cardiopulmonary bypass for pulmonary valve replacement in patients with repaired tetralogy of Fallot. Interact Cardiovasc Thorac Surg 2017; 25:370-376. [PMID: 28535202 DOI: 10.1093/icvts/ivx148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 03/21/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES This study aimed to compare the effects of hypothermic ventricular fibrillation and beating-heart techniques during cardiopulmonary bypass (CPB) on postoperative outcomes after simple pulmonary valve replacement in patients with repaired tetralogy of Fallot (TOF). METHODS We retrospectively reviewed the data of 47 patients with repaired tetralogy of Fallot at a single institution, who received pulmonary valve replacement under the ventricular fibrillation or beating-heart technique without cardioplegic cardiac arrest during CPB between January 2005 and April 2015. RESULTS The patients were divided into fibrillation (n = 32) and beating-heart (n = 15) groups. On comparing these groups, the fibrillation group had a larger sinotubular junction (27.1 ± 4.6 vs 22.1 ± 2.4 mm), had a longer operation duration (396 ± 108 vs 345 ± 57 min), required more postoperative transfusions (2.1 ± 2.6 vs 5.0 ± 6.3 units) and had a higher vasoactive-inotropic score at intensive care unit admission (8.0 vs 10, all P < 0.05). Echocardiographic data indicated that the systolic internal diameter of the left ventricle was larger in the fibrillation group than in the beating-heart group immediately after surgery and at the 1-year follow-up. Major adverse cardiac events occurred in 3 cases, all from the fibrillation group. Among 7 patients from the fibrillation group with transoesophageal echocardiography data during CPB, 6 had fully opened aortic valves during fibrillation, causing flooding into the left ventricle and left ventricle distension. CONCLUSIONS The postoperative outcomes are worse with the ventricular fibrillation technique than with the beating-heart technique during CPB for pulmonary valve replacement in patients with repaired tetralogy of Fallot.
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Affiliation(s)
- Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Jongnogu, Seoul, Republic of Korea
| | - Ji-Eun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Jongnogu, Seoul, Republic of Korea
| | - Jungho Shin
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Jongnogu, Seoul, Republic of Korea
| | - In-Kyung Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Jongnogu, Seoul, Republic of Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Jongnogu, Seoul, Republic of Korea
| | - Chong-Sung Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Jongnogu, Seoul, Republic of Korea
| | - Woong-Han Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Jongnogu, Seoul, Republic of Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Jongnogu, Seoul, Republic of Korea
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Cardiomyopathy in children: Can we rely on echocardiographic tricuspid regurgitation gradient estimates of right ventricular and pulmonary arterial pressure? Cardiol Young 2016; 26:1406-13. [PMID: 26940013 DOI: 10.1017/s1047951116000020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED Introduction Agreement between echocardiography and right heart catheterisation-derived right ventricular systolic pressure is modest in the adult heart failure population, but is unknown in the paediatric cardiomyopathy population. METHODS All patients at a single centre from 2001 to 2012 with a diagnosis of cardiomyopathy who underwent echocardiography and catheterisation within 30 days were included in this study. The correlation between tricuspid regurgitation gradient and catheterisation-derived right ventricular systolic pressure and mean pulmonary artery pressure was determined. Agreement between echocardiography and catheterisation-derived right ventricular systolic pressure was assessed using Bland-Altman plots. Analysis was repeated for patients who underwent both procedures within 7 days. Haemodynamic data from those with poor agreement and good agreement between echocardiography and catheterisation were compared. RESULTS A total of 37 patients who underwent 48 catheterisation procedures were included in our study. The median age was 11.8 (0.1-20.6 years) with 22 males (58% total). There was a modest correlation (r=0.65) between echocardiography and catheterisation-derived right ventricular systolic pressure, but agreement was poor. Agreement between tricuspid regurgitation gradient and right ventricular systolic pressure showed wide 95% limits of agreement. There was a modest correlation between the tricuspid regurgitation gradient and mean pulmonary artery pressure (r=0.6). Shorter time interval between the two studies did not improve agreement. Those with poor agreement between echocardiography and catheterisation had higher right heart pressures, but this difference became insignificant after accounting for right atrial pressure. CONCLUSION Transthoracic echocardiography estimation of right ventricular systolic pressure shows modest correlation with right heart pressures, but has limited agreement and may underestimate the degree of pulmonary hypertension in paediatric cardiomyopathy patients.
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Sinha N, Devabhaktuni S, Kadambi A, McClung JA, Aronow WS, Lehrman SG. Can echocardiographically estimated pulmonary arterial elastance be a non-invasive predictor of pulmonary vascular resistance? Arch Med Sci 2014; 10:692-700. [PMID: 25276152 PMCID: PMC4175770 DOI: 10.5114/aoms.2014.44860] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Revised: 10/20/2013] [Accepted: 11/10/2013] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Measurement of pulmonary vascular resistance (PVR) is essential in evaluating a patient with pulmonary hypertension. MATERIAL AND METHODS Data from right heart catheterization (RHC) and echocardiograms performed within 90 days of each other on 45 non-consecutive adult patients were reviewed in this retrospective study. Patients were recruited using an assortment of strategies to ensure the presence of patients with a wide range of PVR. RESULTS The linear regression equation between RHC-derived PVR and echocardiographic pulmonary arterial elastance (PAE) was: PVR = (562.6 × PAE) - 38.9 (R = 0.56, p < 0.0001). An adjustment for echocardiographic PAE was made by multiplying it by hemoglobin (in g/dl) and (right atrial area)(1.5) (in cm(3)). As RHC-derived PVR varies with blood hemoglobin, an adjustment for PVR was made for hemoglobin of 12 g/dl. Visualization of the XY scatter plot of adjusted PVR and adjusted PAE isolated a subset of patients with PVR higher than 8.8 Wood units, where a strong linear relationship existed (adjusted PVR = (0.89 × adjusted PAE) + 137.4, R = 0.89, p = 0.008). CONCLUSIONS The correlation coefficient of the regression equation connecting echocardiographic PAE and RHC-derived PVR was moderate. In a subset of patients with very high PVR and after appropriate adjustment, a strong linear relationship existed with an excellent correlation coefficient.
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Affiliation(s)
- Neeraj Sinha
- Division of Pulmonary and Transplantation Medicine, Department of Medicine, The Methodist Hospital, Houston, TX, USA
| | - Srikala Devabhaktuni
- Division of Cardiology, Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Aparna Kadambi
- Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - John A. McClung
- Division of Cardiology, Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Wilbert S. Aronow
- Division of Cardiology, Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Stuart G. Lehrman
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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Groh GK, Levy PT, Holland MR, Murphy JJ, Sekarski TJ, Myers CL, Hartman DP, Roiger RD, Singh GK. Doppler echocardiography inaccurately estimates right ventricular pressure in children with elevated right heart pressure. J Am Soc Echocardiogr 2013; 27:163-71. [PMID: 24183542 DOI: 10.1016/j.echo.2013.09.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND Doppler echocardiography (DE) is widely used as a surrogate for right heart catheterization (RHC), the gold standard, to assess and monitor elevated right heart pressure in children. However, its accuracy has not been prospectively validated in children. The objectives of this study were to evaluate the accuracy of DE in predicting simultaneously measured right ventricular (RV) pressure by RHC in pediatric patients and to determine if the degree of RV hypertension affects the accuracy of DE in assessing right heart pressure. METHODS Eighty children (age range, 0-17.9 years; median age, 5.5 years) with two-ventricle physiology and a wide range of right heart pressures underwent simultaneous DE and RHC. The pressure gradient between the right ventricle and the right atrium was directly measured by RHC and simultaneously estimated by DE using tricuspid regurgitation. Patients were then grouped on the basis of RHC-measured RV systolic pressure (RVSP): group 1 (n = 43), with RVSP < 1/2 systemic systolic blood pressure (SBP); group 2 (n = 37), with RVSP ≥ 1/2 SBP; group 3 (n = 56), with RVSP < 2/3 SBP; and group 4 (n = 24), with RVSP ≥ 2/3 SBP. Correlation and Bland-Altman analyses were performed on all groups. Accuracy was predefined as 95% limits of agreement within ±10 mm Hg. RESULTS Despite a reasonable correlation between DE and RHC in all groups, there was poor agreement between techniques as RVSP/SBP increased. DE was inaccurate in one of 43 patients in group 1 (2%) versus nine of 37 in group 2 (24%) and was inaccurate in one of 56 patients in group 3 (2%) versus eight of 24 in group 4 (33%). Overestimation and underestimation occurred equally in all groups. CONCLUSION DE inaccurately estimates RV pressure in children with elevated right heart pressure. It should not be relied on as the sole method of assessing right heart hemodynamics in children with RV hypertension.
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Affiliation(s)
- Georgeann K Groh
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Philip T Levy
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Mark R Holland
- Department of Physics, Washington University, St. Louis, Missouri
| | - Joshua J Murphy
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Timothy J Sekarski
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Craig L Myers
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Diana P Hartman
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | | | - Gautam K Singh
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri.
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Finkelhor RS, Scrocco JD, Madmani M, Rovner A, Pillai D. Discordant Doppler right heart catheterization pulmonary artery systolic pressures: importance of pulmonary capillary wedge pressure. Echocardiography 2013; 31:279-84. [PMID: 24028340 DOI: 10.1111/echo.12361] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Although the echo Doppler (D) estimation of pulmonary artery systolic pressure (PASP) was initially highly correlated with right heart catheterization (RHC), recent D-RHC studies have questioned its accuracy. The aim of this study was to reevaluate this relationship and to determine possible explanations for disparate D-RHC results. METHODS We retrospectively identified all patients at one institution who underwent RHC and had an echocardiogram within the prior month. Echocardiographic and catheterization hemodynamic factors were evaluated by regression and Bland-Altman analysis. RESULTS Of 69 patients, 52 (75.4%) had estimable D-PASP. D-RHC PASP r = 0.62 and 51.9% had a PASP difference >10 mmHg, comparable to other recent studies. The D-RHC difference correlated with pulmonary capillary wedge pressure (PCWP) (r = -0.60, P < 0.001) and right atrial pressure (r = -0.43, P = 0.002). Multivariate analysis including wedge pressure improved the relation between D and RHC for PASP (r = 0.86). These results were little changed using only the respective RV-RA pressure gradients from D and RHC. CONCLUSION Pulmonary capillary wedge pressure appears to be a significant covariate in the correlation between D and RHC PASP.
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Affiliation(s)
- Robert S Finkelhor
- Case Western Reserve University at the MetroHealth Medical Center Campus, Cleveland, Ohio
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Kirkpatrick EC. Echocardiography in pediatric pulmonary hypertension. Paediatr Respir Rev 2013; 14:157-64. [PMID: 23411118 DOI: 10.1016/j.prrv.2012.12.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Accepted: 12/30/2012] [Indexed: 11/18/2022]
Abstract
Pediatric pulmonary hypertension is a complicated disease with multiple etiologies and high mortality. Echocardiography is at the forefront of evaluation as a noninvasive, portable imaging modality that can yield diagnostic and prognostic information regarding this disease. Echocardiography is known for its ability to give an anatomic assessment of the heart and proximal blood vessels. With the additional use of Doppler echocardiography and myocardial motion assessment, the effects of elevated pulmonary pressures on the heart can be evaluated. This can allow for estimation of pulmonary artery pressures and resistances and assessment of ventricular systolic and diastolic functions. However despite its advantages, echocardiography is still an indirect assessment of pulmonary hypertension and not a substitute for cardiac catheterization. The purpose of this review is to discuss common techniques for the assessment of pulmonary hypertension by echocardiography as well as their limitations.
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Methods for measuring right ventricular function and hemodynamic coupling with the pulmonary vasculature. Ann Biomed Eng 2013; 41:1384-98. [PMID: 23423705 DOI: 10.1007/s10439-013-0752-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 01/21/2013] [Indexed: 12/11/2022]
Abstract
The right ventricle (RV) is a pulsatile pump, the efficiency of which depends on proper hemodynamic coupling with the compliant pulmonary circulation. The RV and pulmonary circulation exhibit structural and functional differences with the more extensively investigated left ventricle (LV) and systemic circulation. In light of these differences, metrics of LV function and efficiency of coupling to the systemic circulation cannot be used without modification to characterize RV function and efficiency of coupling to the pulmonary circulation. In this article, we review RV physiology and mechanics, established and novel methods for measuring RV function and hemodynamic coupling, and findings from application of these methods to RV function and coupling changes with pulmonary hypertension. We especially focus on non-invasive measurements, as these may represent the future for clinical monitoring of disease progression and the effect of drug therapies.
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Giardini A. Limitations Inherent to the Simplified Bernoulli Equation Explain the Inaccuracy of Doppler Echocardiographic Estimates of Pulmonary Artery Pressures in Patients With Pulmonary Hypertension. Chest 2011; 140:270. [DOI: 10.1378/chest.11-0344] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Figliola RS, Giardini A, Conover T, Camp TA, Biglino G, Chiulli J, Hsia TY. In Vitro Simulation and Validation of the Circulation with Congenital Heart Defects. PROGRESS IN PEDIATRIC CARDIOLOGY 2010; 30:71-80. [PMID: 21218147 DOI: 10.1016/j.ppedcard.2010.09.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Despite the recent advances in computational modeling, experimental simulation of the circulation with congenital heart defect using mock flow circuits remains an important tool for device testing, and for detailing the probable flow consequences resulting from surgical and interventional corrections. Validated mock circuits can be applied to qualify the results from novel computational models. New mathematical tools, coupled with advanced clinical imaging methods, allow for improved assessment of experimental circuit performance relative to human function, as well as the potential for patient-specific adaptation. In this review, we address the development of three in vitro mock circuits specific for studies of congenital heart defects. Performance of an in vitro right heart circulation circuit through a series of verification and validation exercises is described, including correlations with animal studies, and quantifying the effects of circuit inertiance on test results. We present our experience in the design of mock circuits suitable for investigations of the characteristics of the Fontan circulation. We use one such mock circuit to evaluate the accuracy of Doppler predictions in the presence of aortic coarctation.
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Affiliation(s)
- Richard S Figliola
- Departments of Mechanical Engineering and Bioengineering, Clemson University, Clemson, SC, USA
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